An Analysis of Water Collection Labor among Women and Children in 24 Sub-Saharan African Countries

Systematic re-review of WASH trials to assess women's engagement in intervention delivery and research activities

Water, sanitation and hygiene (WASH) interventions significantly reduce health risks in low- and middle-income countries. Many rely on women, but the extent of women's engagement remains undocumented. Here we conducted a re-review of papers from two systematic reviews that assessed the effectiveness of water, sanitation and/or handwashing with soap interventions on diarrhoeal disease and acute respiratory infections to assess women's roles in WASH research and intervention activities. A total of 133 studies were included. Among studies that specified gender, women were the most sought-after group for engagement in research (n = 91/132; 68.9%) and intervention (n = 49/120; 40.8%) activities. Reporting time burden for research (n = 1; 1%) and intervention activities (n = 3; 2.5%) was rare. All interventions were classified as gender unequal (36.7%) or gender unaware (63.3%) according to the World Health Organization Gender Responsiveness Assessment Scale, indicating exploitative engagement. Women play a critical but instrumentalized role in WASH, and both research and interventions need to change to enable, and not hinder, gender equality.

Water fetching and musculoskeletal health across the life-course in Sub-Saharan Africa: A scoping review

The world is experiencing a global water crisis and Sub-Saharan Africa (SSA) is expected to be a hotspot for increasing global water scarcity in years to come. Water is quintessentially a gendered issue; indeed, sociocultural norms hold women responsible for household water collection, requiring them to travel far distances while carrying water. This paper reports the findings of a scoping review of peer-reviewed and grey literature that examines the relationship between water fetching and the musculoskeletal (MSK) health of women in SSA. The work is informed by a gendered life-course perspective, and the authors follow the PRISMA-ScR guidelines. Results indicate a bidirectional relationship between water fetching and poor MSK health as chronic and acute incidences of water carrying are highly related to MSK pain and dysfunction. This has negative implications for the overall health and wellbeing of women and their households. Gaps in the literature are identified, including the experiences of elderly people and people with various vulnerabilities. Recommendations from the literature are compiled to outline potential avenues of future research and innovation to better support the MSK health of water fetchers in SSA.

Self-reported musculoskeletal disorder symptoms and associated factors among water carrying women in Legambo district, Northeastern Ethiopia: a community-based cross-sectional study design

Introduction

Musculoskeletal disorders are the leading cause of illness, disability, and poor quality of life. Lack of access to potable water in the backyard forces women to take water from off-plot sources every day, which may expose them to various health risks. However, there has been little investigation on the musculoskeletal disorders' health effects on water-carrying women.

Objective

This study aimed to assess musculoskeletal disorders symptoms and associated factors among water-carrying women in the Legambo district, Northeastern Ethiopia.

Materials and methods

A community-based cross-sectional study was done with 618 water-carrying women chosen using simple random and systematic random sampling techniques. The data were collected using face-to-face interviews with the standard Nordic Musculoskeletal Questionnaire. Data entry were carried out using Epi-data version 4.6 and exported to SPSS version 25.0 for analysis. A binary logistic regression was used to determine the factors associated with self-reported musculoskeletal disorder symptoms at a 95% confidence interval (CI). In the multivariate model, variables with a p-value ≤0.05 and a 95% CI were declared as factors of self-reported musculoskeletal disorder symptoms. The model's fitness was assessed using Hosmer and Lemeshow, and it was found to be fit.

Results

The prevalence of self-reported MSD symptoms was 72.5% during the previous 12 months. MSD symptoms were significantly elevated among women who carried water from a distance of 501-1,000 m [adjusted odds ratio (AOR) = 5.39, 95% CI = 3.64-9.69] and >1,000 m (5.93, 2.84-12.40), carried a water load of >15 kg during pregnancy (8.29, 2.97-23.09), and carried a water load of >15 kg when not pregnant (1.59, 1.44-2.68).

Conclusion

Three-fourths of the participants had self-reported musculoskeletal disorder symptoms in the past 12 months. Distance of water sources from their house, carrying the same amount of water during pregnancy, and weight of the water load carrying were factors associated with the self-reported musculoskeletal disorder symptoms. Hence, health professionals should raise awareness of the association between carrying high water loads and the development of MSDs, especially during pregnancy. Improvement in water supply infrastructure and enhancing behavioral intervention should be done. Furthermore, Future researchers should assess MSDs using objective measurements and cohort studies should be implemented.

Advancing disability-inclusive climate research and action, climate justice, and climate-resilient development

Globally, more than 1 billion people with disabilities are disproportionately and differentially at risk from the climate crisis. Yet there is a notable absence of climate policy, programming, and research at the intersection of disability and climate change. Advancing climate justice urgently requires accelerated disability-inclusive climate action. We present pivotal research recommendations and guidance to advance disability-inclusive climate research and responses identified by a global interdisciplinary group of experts in disability, climate change, sustainable development, public health, environmental justice, humanitarianism, gender, Indigeneity, mental health, law, and planetary health. Climate-resilient development is a framework for enabling universal sustainable development. Advancing inclusive climate-resilient development requires a disability human rights approach that deepens understanding of how societal choices and actions-characterised by meaningful participation, inclusion, knowledge diversity in decision making, and co-design by and with people with disabilities and their representative organisations-build collective climate resilience benefiting disability communities and society at large while advancing planetary health.

High salinity in drinking water creating pathways towards chronic poverty: A case study of coastal communities in Tanzania

Seawater intrusion is a growing pressure in coastal communities worldwide, putting millions of people at risk of excess salinity in drinking water. This study examines the impact of saline water on people's health and labor allocation as potential pathways towards chronic poverty. Using a transdisciplinary approach based on a coupled human-water system framework, we test these linkages combining field data on well water salinity levels and rich household survey data in coastal Tanzania. The results suggest that increased salinity levels lead to more time spent collecting drinking water and an increase in illnesses. Moreover, households in poorer villages with weaker public infrastructure have limited access to alternative sources of drinking water, making them more vulnerable to scarce potable water resources stemming from high salinity. To prevent chronic poverty, communities vulnerable to saline drinking water need better adaptation strategies as well as groundwater monitoring and management.

The association between access to key household resources and violence against women

We provide the first comprehensive analysis of the association between two key household resources (drinking water and toilet access) and both non-partner violence (NPV) and intimate partner violence (IPV) experienced by women. We use data from a nationally representative household survey for India obtained from the latest (fourth) round of the National Family Health Survey conducted in 2015-16. We employ logistic regression method and also use inverse-probability-weighted regression adjustment to control for selection bias. We find that NPV decreases with access to drinking water, while IPV decreases with provision of toilets. These results are found to be robust to an alternative method viz. propensity score matching and selection on unobservables using the Rosenbaum bounds approach.

Assessing the social and economic implications on water security in the Nelson Mandela Bay Metropolitan Municipality, Eastern Cape of South Africa

Access to water is a universal human right for every individual and a key instrument in meeting the United Nations' sustainable development goal SDG 6, namely, to ensure safe drinking water and sanitation for all by 2030. Water is also intrinsically linked to any society or country's social, economic and political development. Nevertheless, many communities and households, predominantly rural and underprivileged in the Nelson Mandela Metropolitan Municipality, continue to experience persistent water shortages. This means entrenched poverty, ill health, hunger, stress, and social and economic challenges for the population. Using data collection tools inspired by traditional methods of qualitative and quantitative approaches, this paper scrutinised the social and economic factors contributing to severe inequality in water access in the municipality. Our findings established that water shortage is portrayed as a stand-alone issue without linking it to social and economic challenges. Furthermore, both government and municipalities fail to contextualise a multidimensional problem-solving approach to the water provision challenges in the municipality. This paper, therefore, recommends a multidimensional approach to tackling the problem of accessibility, taking into consideration the social and economic needs of the population.

Burden of disease attributable to unsafe drinking water, sanitation, and hygiene in domestic settings: a global analysis for selected adverse health outcomes

BACKGROUND

Assessments of disease burden are important to inform national, regional, and global strategies and to guide investment. We aimed to estimate the drinking water, sanitation, and hygiene (WASH)-attributable burden of disease for diarrhoea, acute respiratory infections, undernutrition, and soil-transmitted helminthiasis, using the WASH service levels used to monitor the UN Sustainable Development Goals (SDGs) as counterfactual minimum risk-exposure levels.

METHODS

We assessed the WASH-attributable disease burden of the four health outcomes overall and disaggregated by region, age, and sex for the year 2019. We calculated WASH-attributable fractions of diarrhoea and acute respiratory infections by country using modelled WASH exposures and exposure-response relationships from two updated meta-analyses. We used the WHO and UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene public database to estimate population exposure to different WASH service levels. WASH-attributable undernutrition was estimated by combining the population attributable fractions (PAF) of diarrhoea caused by unsafe WASH and the PAF of undernutrition caused by diarrhoea. Soil-transmitted helminthiasis was fully attributed to unsafe WASH.

FINDINGS

We estimate that 1·4 (95% CI 1·3-1·5) million deaths and 74 (68-80) million disability-adjusted life-years (DALYs) could have been prevented by safe WASH in 2019 across the four designated outcomes, representing 2·5% of global deaths and 2·9% of global DALYs from all causes. The proportion of diarrhoea that is attributable to unsafe WASH is 0·69 (0·65-0·72), 0·14 (0·13-0·17) for acute respiratory infections, and 0·10 (0·09-0·10) for undernutrition, and we assume that the entire disease burden from soil-transmitted helminthiasis was attributable to unsafe WASH.

INTERPRETATION

WASH-attributable burden of disease estimates based on the levels of service established under the SDG framework show that progress towards the internationally agreed goal of safely managed WASH services for all would yield major public-health returns.

FUNDING

WHO and Foreign, Commonwealth & Development Office.

Awareness and interventions to reduce dehydration in pregnant, postpartum women, and newborns in rural Kenya

Extreme heat exposure is associated with adverse outcomes in pregnancy and has the potential to impact maternal, neonatal and child health for a lifetime. In an extremely hot climate, pregnant women face an increased risk of premature birth, stillbirth, low birth weight, congenital anomalies and pre-eclampsia. In low- and middle-income countries (LMICs), socio-demographic and behavioural practices may negatively affect body hydration during high temperatures. The possible causes and consequences of dehydration in the heat are poorly understood and have been little discussed in the literature.Living in a hot climate poses various challenges, including dehydration, where biological mechanisms and insufficient access to water can lead to dehydration in women and children, with consequences for the health of both mothers and children, particularly in relation to breastfeeding habits. During pregnancy, increased metabolic and cardiovascular demands interact with heat exhaustion and reduced availability of fresh water, which can affect the child's growth and development. In this opinion piece, we emphasise the possible causes and impacts of dehydration in extreme heat on the health and well-being of mothers and children. We encourage more research, focused on biology and epidemiology, related to raising awareness and implementing adaptations to reduce the risk of dehydration in pregnant, postpartum women and newborns in the context of climate change-related heat exposure.

Does small-scale irrigation provide a pathway to women's empowerment? Lessons from Northern Ghana

Given persistent gender inequalities that influence how the benefits of technologies are distributed, the expansion of small-scale irrigation technologies requires the consideration of important gender dynamics and impacts. Women's lack of agency and access to resources relative to men, and other social constraints, often limit their ability to adopt and benefit from agricultural technologies. At the same time, expanding access to agricultural technology to women may provide a pathway for empowerment. This paper explores the potential for small-scale irrigation technologies to increase women's empowerment by evaluating the impacts of an intervention that distributed motor pumps to small groups of farmers in Northern Ghana. The paper draws on two rounds of survey data that included the Women's Empowerment in Agriculture Index, before and after the motor pump intervention was implemented. To control for possible selection bias at the baseline, the difference-in-difference method is used to estimate the impact of the program on indicators of women's empowerment. Spillover effects are estimated by comparing outcomes of farmers in treatment villages that did not receive the pumps with farmers in control villages, where no motor pumps were distributed. The results show no significant impact of the program on measures of women's empowerment. However, there are potential negative impacts, including among households that did not benefit from the intervention. The results highlight the need to pair interventions that distribute agricultural technologies with complementary investments in infrastructure that increase access to water for irrigation, as well as other activities and approaches that ensure women can reap the benefits.

Drinking water and the implications for gender equity and empowerment: A systematic review of qualitative and quantitative evidence

BACKGROUND

Safe drinking water is a fundamental human right, yet more than 785 million people do not have access to it. The burden of water management disproportionately falls on women and young girls, and they suffer the health, psychosocial, political, educational, and economic effects. While water conditions and disease outcomes have been widely studied, few studies have summarized the research on drinking water and implications for gender equity and empowerment (GEE).

METHODS

A systematic review of primary literature published between 1980 and 2019 was conducted on drinking water exposures and management and the implications for GEE. Ten databases were utilized (EMBASE, PubMed, Web of Science, Cochrane, ProQuest, Campbell, the British Library for Development Studies, SSRN, 3ie International Initiative for Impact Evaluation, and clinicaltrials.gov). Drinking water studies with an all-female cohort or disaggregated findings according to gender were included.

RESULTS

A total of 1280 studies were included. GEE outcomes were summarized in five areas: health, psychosocial stress, political power and decision-making, social-educational conditions, and economic and time-use conditions. Water quality exposures and implications for women's health dominated the literature reviewed. Women experienced higher rates of bladder cancer when exposed to arsenic, trihalomethanes, and chlorine in drinking water and higher rates of breast cancer due to arsenic, trichloroethylene, and disinfection byproducts in drinking water, compared to men. Women that were exposed to arsenic experienced higher incidence rates of anemia and adverse pregnancy outcomes compared to those that were not exposed. Water-related skin diseases were associated with increased levels of psychosocial stress and social ostracization among women. Women had fewer decision-making responsibilities, economic independence, and employment opportunities around water compared to men.

CONCLUSION

This systematic review confirms the interconnected nature of gender and WaSH outcomes. With growing attention directed towards gender equity and empowerment within WaSH, this analysis provides key insights to inform future research and policy.

Assessing the relationship between domestic work experience and musculoskeletal health among rural Nigerian women

BACKGROUND

Women performing strenuous domestic tasks (especially those in developing countries) are at risk of experiencing musculoskeletal pain (MSP). Physical, psychosocial, and social conditions of work in rural environments contribute to women's domestic work experiences (DWEs) and the risk of MSP. The impact of DWEs on women's health is especially severe in water-insecure countries like Nigeria. This study examines the relationship between a recently developed measure of DWEs and self-reported pain in the lower back (LBP), neck/shoulder (NSP), and elbow/hand/wrist regions (EHWP) among rural Nigerian women.

METHODS

Interviewer-administered survey data were collected from 356 women in four rural communities of Ibadan, Nigeria. Binary and ordinal logistic regression models were used to examine the relationship between DWE factor scores, sociodemographic characteristics, and musculoskeletal pain symptoms and severity after controlling for sociodemographic covariates. Effect estimates of association were presented using the odds ratio (OR), and the corresponding 95% confidence interval (CI) at p-value of 0.05.

FINDINGS

Among 356 participants, the 2-month prevalence of LBP was 58%, NSP was 30%, and EWHP 30%. High DWE scores were significantly associated with higher odds of experiencing and having more severe LBP, NSP, and EHWP. Specifically, the odds of LBP [(OR = 2.88; 95% CI = 1.64-5.11), NSP (OR = 4.58; 95% CI = 2.29-9.40) and EHWP (OR = 1.88; 95% CI = 1.26-3.77)] were significantly higher among women who perceived their domestic work responsibilities as very stressful (i.e., 'high stress appraisal') compared to those with lower stress appraisal scores. Those who were time-pressured and had less autonomy over familial duties (i.e., 'high demand/low control') had significantly higher odds of LBP [(OR = 2.58; 95% CI = 1.64-4.09) and NSP (OR = 1.49; 95% CI = 1.24-2.58)]. Frequently fetching and carrying water over long distances and time (i.e., 'high water sourcing and carriage') was also associated with higher odds of LBP [(OR = 1.31; 95% CI = 1.09-1.79) and NSP (OR = 1.20; 95% CI = 1.08-1.76).

CONCLUSION

Strenuous and stressful DWEs were associated with MSP among rural Nigerian women. This study provides new evidence on how the physical, social, and psychosocial factors of domestic work can increase women's risk of MSP.

Health gender gap in Uganda: do weather effects and water play a role?

BACKGROUND

Vulnerabilities of men and women to adverse health effects due to weather variability and climate change are not equal. Uganda was among the countries in the world most affected by extreme weather events during the last decade. However, there is still limited gendered empirical evidence on the links between weather variability and health and the possible pathways through which these health effects occur. Therefore, this study analyses the effect of weather variability on illness, and the extent to which water collection 'time burden' mediates the relationship between weather anomalies and illness among men and women of working age in Uganda. The study also quantifies the health inequalities to be eliminated if resources are equalized.

METHODS

Socioeconomic, health and time use data were obtained from the World Bank Living Standards Measurement Studies - Integrated Surveys on Agriculture (LSMS -ISA), combined with high resolution remotely-sensed weather data. Two-parts and non-linear decomposition regression analysis were used on the national representative pooled dataset from the four household survey waves collected between 2009 to 2014, comprising a total of 22,469 men and women aged between 15 and 64 years.

RESULTS

Empirical results show that low rainfall below the long-term mean increased the likelihood of illness by at least 8 and 6 percentage points for women and men, respectively. The indirect effect of low rainfall on illness through water access pathway was estimated at 0.16 percentage points in women. Decomposition results reveal that health inequalities among women and men would have been narrowed by 27-61%, if endowments were equalized.

CONCLUSIONS

Strategies that promote women empowerment (such as education, labor force participation, access to financial services and clean water), health adaptation and time poverty reduction strategies (such as rain water harvesting and improved access to quality health care) would reduce gender-based health inequalities in Uganda despite changing climatic conditions.

Growth and growth trajectory among infants in early life: contributions of food insecurity and water insecurity in rural Zimbabwe

Introduction

Stunting or linear growth faltering, measured by length-for-age Z-score (LAZ), remains a significant public health challenge, particularly in rural low-income and middle-income countries. It is a marker of inadequate environments in which infants are born and raised. However, the contributions of household resource insecurities, such as food and water, to growth and growth trajectory are understudied.

Methods

We used the cluster-randomised Sanitation Hygiene and Infant Nutrition Efficacy trial to determine the association of household-level food insecurity (FI) and water insecurity (WI) on LAZ and LAZ trajectory among infants during early life. Dimensions of FI (poor access, household shocks, low availability and quality) and WI (poor access, poor quality, low reliability) were assessed with the multidimensional household food insecurity and the multidimensional household water insecurity measures. Infant length was converted to LAZ based on the 2006 WHO Child Growth Standards. We report the FI and WI fixed effects from multivariable growth curve models with repeated measures of LAZ at 1, 3, 6, 12 and 18 months (M1-M18).

Results

A total of 714 and 710 infants were included in our analyses of LAZ from M1 to M18 and M6 to M18, respectively. Mean LAZ values at each time indicated worsening linear growth. From M1 to M18, low food availability and quality was associated with lower LAZ (β=-0.09; 95% -0.19 to -0.13). From M6 to M18, poor food access was associated with lower LAZ (β=-0.11; 95% -0.20 to -0.03). None of the WI dimensions were associated with LAZ, nor with LAZ trajectory over time.

Conclusion

FI, but not WI, was associated with poor linear growth among rural Zimbabwean infants. Specifically, low food availability and quality and poor food access was associated with lower LAZ. There is no evidence of an effect of FI or WI on LAZ trajectory.

Water Insecurity, Water Borrowing, and Psychosocial Stress Among Daasanach Pastoralists in Northern Kenya

This article quantifies Daasanach water insecurity experiences in Northern Kenya, examines how water insecurity is associated with water borrowing and psychosocial stress, and evaluates if water borrowing mitigates the stress from water insecurity. Of 133 households interviewed in 7 communities, 94% were water insecure and 74.4% borrowed water three or more times in the prior month. Regression analyses demonstrate water borrowing frequency moderates the relationship between water insecurity and psychosocial stress. Only those who rarely or never borrowed water reported greater stress with higher water insecurity. The coping mechanism of water borrowing may help blunt water insecurity-related stress.

Implementation and maintenance of infant dietary diversity in Zimbabwe: contribution of food and water insecurity

Background

Inadequate food and water resources negatively affect child health and the efficiency of nutrition interventions.

Methods

We used data from the SHINE trial to investigate the associations of food insecurity (FI) and water insecurity (WI) on mothers’ implementation and maintenance of minimum infant dietary diversity (MIDD). We conducted factor analysis to identify and score dimensions of FI (poor access, household shocks, low availability & quality), and WI (poor access, poor quality and low reliability). MIDD implementation (n = 636) was adequate if infants aged 12 months (M12) ate ≥ four food groups. MIDD maintenance (n = 624) was categorized into four mutually exclusive groups: A (unmet MIDD at both M12 and M18), B (unmet MIDD at M12 only), C (unmet MIDD at M18 only), and D (met MIDD at both M12 and M18). We used multivariable-adjusted binary logistic and multinomial regressions to determine likelihood of MIDD implementation, and of belonging to MIDD maintenance groups A-C (poor maintenance groups), compared to group D, respectively.

Results

Low food availability & quality were negatively associated with implementation (OR = 0.81; 0.69, 0.97), and maintenance (ORB = 1.29; 1.07, 1.56). Poor water quality was positively associated with implementation (OR = 1.25; 1.08, 1.44), but inconsistently associated with maintenance, with higher odds of infants being in group C (OR = 1.39; 1.08, 1.79), and lower odds of being in group B (OR = 0.80; 0.66, 0.96).

Conclusion

Food security should be prioritized for adequate implementation and maintenance of infant diets during complementary feeding. The inconsistent findings with water quality indicate the need for further research on WI and infant feeding.

Estimating national, demographic, and socioeconomic disparities in water insecurity experiences in low-income and middle-income countries in 2020-21: a cross-sectional, observational study using nationally representative survey data

BACKGROUND

We are facing a global water crisis. However, because most water indicators assess physical availability or infrastructure in aggregate, knowing which sociodemographic groups experience water insecurity is difficult. We aimed to assess the prevalence of water insecurity across low-income and middle-income countries (LMICs) and examine how it varies by sociodemographic characteristics and exposure to life disruptions due to the COVID-19 pandemic across and within countries.

METHODS

In this observational study, we used Individual Water Insecurity Experiences (IWISE) scale data from a cross-sectional, nationally representative sample of individuals aged 15 years and older (defined as adults) in 31 LMICs. The IWISE scale range is 0-36, and water insecurity was defined as a score of 12 or higher. We used multivariable linear regression models to assess how individual-level experiences with water insecurity related to sociodemographic characteristics in each country, region, and the pooled sample.

FINDINGS

45 555 individuals from 31 LMICs completed the IWISE module between Sept 4, 2020, and Feb 24, 2021, and were included in the 2020 Gallup World Poll (GWP) database; 45 365 individuals had sufficient data to estimate the prevalence of water insecurity. 42 918 individuals from 30 LMICs had sufficient data to assess sociodemographic characteristics associated with water insecurity, and 39 161 individuals in 29 countries had sufficient data to assess how IWISE scale scores covaried with life disruptions due to the COVID-19 pandemic. The overall prevalence of water insecurity in 2020 was 14·2%, ranging by region from 36·1% in the sub-Saharan Africa region to 9·1% in the Asia region, and by country from 63·9% in Cameroon to 3·6% in China. In the pooled model including sociodemographic and COVID-19 factors, difficulty getting by on household income (vs no difficulty getting by: β 2·76 [95% CI 2·45-3·07]), living in the outskirts of a city (vs living in a large city: 0·85 [0·29-1·41]), and being greatly affected by the COVID-19 pandemic (vs not being affected: 2·36 [1·96-2·77]) were strongly associated with higher IWISE scores. In country and regional models, the sociodemographic factors most consistently associated with higher IWISE scores were difficulty getting by on household income and life disruptions due to the COVID-19 pandemic, but the strength of these associations varied across countries and regions.

INTERPRETATION

Through extrapolation of these nationally representative data, we estimate that hundreds of millions of people had life-altering experiences with water insecurity globally in 2020, and that their sociodemographic characteristics vary by country and region. Additional individual-level measurements globally could help pinpoint the characteristics of those who are most water insecure, thereby guiding the development of context-specific policy and interventions that will best serve those most affected.

FUNDING

Carnegie Corporation, Northwestern University, and USAID.

Global arsenic dilemma and sustainability

Arsenic (As) is one of the most prolific natural contaminants in water resources, and hence, it has been recognized as an emerging global problem. Arsenic exposure through food exports and imports, such as As-contaminated rice and cereal-based baby food, is a potential risk worldwide. However, ensuring As-safe drinking water and food for the globe is still not stated explicitly as a right neither in the United Nations' Universal Declaration of Human Rights and the 2030 Sustainable Development Goals (SDGs) nor the global UNESCO priorities. Despite these omissions, addressing As contamination is crucial to ensure and achieve many of the declared human rights, SDGs, and global UNESCO priorities. An international platform for sharing knowledge, experience, and resources through an integrated global network of scientists, professionals, and early career researchers on multidisciplinary aspects of As research can act as an umbrella covering the activities of UN, UNESCO, and other UN organizations. This can deal with the mitigation of As contamination, thus contributing to global economic development and human health. This article provides a perspective on the global As problem for sustainable As mitigation on a global scale by 2030.

A qualitative assessment of gender roles in child nutrition in Central Malawi

Background

Child malnutrition persists globally with men and women playing distinct roles to support children’s nutrition. Women frequently carry the bulk of the workload related to food, care, and health, all of which are critical factors in child nutrition. For this reason, development efforts have emphasised women ignoring the potential role of men in supporting children’s nutrition. This study sought to understand the different roles that Malawian men and women play in children’s nutrition.

Methods

This qualitative was conducted in rural Central Malawi as part of a baseline study in 2017 for the CARE Southern Africa Nutrition Initiative. Seventy-six participants were interviewed, including 19 men and 57 women, using focus group discussions and in-depth interviews. We sought to understand the gender distribution of men’s and women’s roles and how these roles influence child nutrition.

Results

We found that both men and women were involved in productive, reproductive, and community work. However, consistent with the literature, women carried a disproportionate workload in supporting child nutrition compared to men. Women’s heavier workloads often prevented them from being able to meet children’s food needs. Nevertheless, shifts in gender roles were observed in some of the sampled communities, with men taking up responsibilities that have been typically associated with women. These changes in gender roles, however, did not necessarily increase women’s power within the household.

Conclusions

Traditional gender roles remain prevalent in the sampled communities. Women continue to be primarily responsible for the food, care, and health of the household. Women’s heavy workloads prevent them from providing optimal care and nutrition for children. While efforts to advance gender equality by encouraging men to participate in child care and other household responsibilities appear to have had marginal success, the extent to which these efforts have successfully encouraged men to share power remains unclear. Improving gender equality and child nutrition will require efforts to redistribute gendered work and encourage men to move towards shared power with women over household decision-making and control over income.

Effectiveness of interventions to improve drinking water, sanitation, and handwashing with soap on risk of diarrhoeal disease in children in low-income and middle-income settings: a systematic review and meta-analysis

BACKGROUND

Estimates of the effectiveness of water, sanitation, and hygiene (WASH) interventions that provide high levels of service on childhood diarrhoea are scarce. We aimed to provide up-to-date estimates on the burden of disease attributable to WASH and on the effects of different types of WASH interventions on childhood diarrhoea in low-income and middle-income countries (LMICs).

METHODS

In this systematic review and meta-analysis, we updated previous reviews following their search strategy by searching MEDLINE, Embase, Scopus, Cochrane Library, and BIOSIS Citation Index for studies of basic WASH interventions and of WASH interventions providing a high level of service, published between Jan 1, 2016, and May 25, 2021. We included randomised and non-randomised controlled trials conducted at household or community level that matched exposure categories of the so-called service ladder approach of the Sustainable Development Goal (SDG) for WASH. Two reviewers independently extracted study-level data and assessed risk of bias using a modified Newcastle-Ottawa Scale and certainty of evidence using a modified Grading of Recommendations, Assessment, Development, and Evaluation approach. We analysed extracted relative risks (RRs) and 95% CIs using random-effects meta-analyses and meta-regression models. This study is registered with PROSPERO, CRD42016043164.

FINDINGS

19 837 records were identified from the search, of which 124 studies were included, providing 83 water (62 616 children), 20 sanitation (40 799 children), and 41 hygiene (98 416 children) comparisons. Compared with untreated water from an unimproved source, risk of diarrhoea was reduced by up to 50% with water treated at point of use (POU): filtration (n=23 studies; RR 0·50 [95% CI 0·41-0·60]), solar treatment (n=13; 0·63 [0·50-0·80]), and chlorination (n=25; 0·66 [0·56-0·77]). Compared with an unimproved source, provision of an improved drinking water supply on premises with higher water quality reduced diarrhoea risk by 52% (n=2; 0·48 [0·26-0·87]). Overall, sanitation interventions reduced diarrhoea risk by 24% (0·76 [0·61-0·94]). Compared with unimproved sanitation, providing sewer connection reduced diarrhoea risk by 47% (n=5; 0·53 [0·30-0·93]). Promotion of handwashing with soap reduced diarrhoea risk by 30% (0·70 [0·64-0·76]).

INTERPRETATION

WASH interventions reduced risk of diarrhoea in children in LMICs. Interventions supplying either water filtered at POU, higher water quality from an improved source on premises, or basic sanitation services with sewer connection were associated with increased reductions. Our results support higher service levels called for under SDG 6. Notably, no studies evaluated interventions that delivered access to safely managed WASH services, the level of service to which universal coverage by 2030 is committed under the SDG.

FUNDING

WHO, Foreign, Commonwealth & Development Office, and National Institute of Environmental Health Sciences.

Water carrying in hills of Nepal–associations with women’s musculoskeletal disorders, uterine prolapse, and spontaneous abortions

More than a third of women in Nepal have to carry water from source to home to satisfy their families’ daily needs. A cross-sectional study was carried out in a hilly area in Nepal to assess water-carrying practices and their association with women’s health. Quantitative interviews were conducted with 1001 women of reproductive age and were complemented with health surveys carried out by health professionals and structured observations of water carrying. Multivariate mixed logistic regression models were used to assess the associations between water-carrying-related risk factors and health issues for women. Around 46% of women faced considerably increased to excessive physical stress due to water carrying during the dry season. Women suffered from a disproportionately high prevalence of back pain (61%), with about 18% of this pain being horrible to excruciating; pain in the knees (34%); uterine prolapse (11.3%); and at least one spontaneous abortion (9%). The risk category of water carrying was significantly associated with uterine prolapse (OR = 1.44, 95%CI = 1.12–1.85, p = 0.031) and pain in the hips (OR = 1.69, 95%CI = 1.27–2.26, p<0.001). Receiving help with water carrying during pregnancy and during the first three months after delivery was associated with reduced odds ratios for uterine prolapse (OR = 0.10, 95% CI = 0.01–0.87, p = 0.037), and strong back pain (OR = 0.32, 95% CI = 0.12–0.87, p = 0.026). Improvements to water supply infrastructure and the promotion of social support for carrying water during pregnancy and after delivery are recommended to reduce water-carrying-related health risks.

Annual Research Review: Cross-cultural similarities and differences in parenting

This article reviews contemporary research on cross-cultural similarities and differences in parenting. The article begins by providing a definition of culture and how both parenting and culture can change over historical time. The article then presents some classic theoretical frameworks for understanding culture and parenting before considering why parenting may be similar across cultures and why parenting may be different across cultures. The article next turns to a review of cross-cultural similarities and differences in several aspects of parenting, including physical caregiving, cognitive stimulation, warmth and acceptance, control and monitoring, and discipline. Cultural normativeness and beliefs on the legitimacy of parental authority are then considered as potential moderators that contribute to cross-cultural similarities and differences in relations between parenting and child outcomes. The article then considers implications for parenting interventions and laws and policies related to parenting. Finally, the article suggests directions for future research.

Assessing Waterborne Disease Vulnerabilities in the Blocks of Kalahandi District of Odisha, India

Background:

Outbreaks of waterborne diseases caused by the contamination of water in the rural and tribal regions have become an area of prime concern in the research arena. The impact and intensity of waterborne diseases are expected to increase in these socioeconomic backward regions.

Objective:

The purpose of the study is to calculate the waterborne disease vulnerability index (DVI) for 13 blocks of the Kalahandi district of Odisha. Diarrhea and typhoid are two major diseases prevailing in each block of the district.

Materials and Methods:

Livelihood vulnerability index has been applied with some modifications to calculate the DVI for each block. In the DVI calculation, diseases are taken as an indicator for the exposure section. The sensitivity and adaptive capacity sections are categorized into two subcomponents to study the vulnerability of each block.

Results:

We have observed uneven distribution of diarrhea and typhoid among the blocks of Kalahandi. The result indicates that vulnerable populations and infrastructure play an important role in enhancing vulnerability whereas educational and health-care capacity reduces its impact. We have found that more than 50% of blocks in the district are categorized in moderate to high vulnerable zones.

Conclusion:

This study is done to understand the relationship between disease exposure, related vulnerability, and adaptive capacity. It is unique in the way the indicators have been chosen in the proposed method for the calculation of DVI and will have a higher degree of practical applicability.

Drinking Water Insecurity in Southwest Coastal Bangladesh: How Far to SDG 6.1?

Substantial progress has been seen in the drinking water supply as per the Millennium Development Goals (MDG), but achieving the Sustainable Development Goals (SDG), particularly SGD 6.1 regarding safely managed drinking water with much more stringent targets, is considered as a development challenge. The problem is more acute in low-income water-scarce hard-to-reach areas such as the southwest coastal region of Bangladesh, where complex hydrogeological conditions and adverse water quality contribute to a highly vulnerable and insecure water environment. Following the background, this study investigated the challenges and potential solutions to drinking water insecurity in a water-scarce area of southwest coastal Bangladesh using a mixed-methods approach. The findings revealed that water insecurity arises from unimproved, deteriorated, unaffordable, and unreliable sources that have significant time and distance burdens. High rates of technical dysfunction of the existing water infrastructure contribute to water insecurity as well. Consequently, safely managed water services are accessible to only 12% of the population, whereas 64% of the population does not have basic water. To reach the SDG 6.1 target, this underserved community needs well-functioning readily accessible water infrastructure with formal institutional arrangement rather than self-governance, which seems unsuccessful in this low-income context. This study will help the government and its development partners in implementing SDG action plans around investments to a reliable supply of safe water to the people living in water-scarce hard-to-reach coastal areas.

Understanding Rural Women's Domestic Work Experiences (DWE) in Ibadan, Nigeria: Development of a Measurement Tool Using Confirmatory Factor Analysis

Gender norms prescribe domestic labor as primarily a female's responsibility in developing countries. Many domestic tasks depend on access to water, so the physical, emotional, and time demands of domestic labor may be exacerbated for women living in water-insecure environments. We developed a set of domestic work experience (DWE) measures tailored to work in rural areas in developing countries, assessed rural Nigerian women's DWE, and examined relationships among the measures. Interviewer-administered survey data were collected between August and September from 256 women in four rural Nigerian communities. Latent factors of DWE were identified by analyzing survey items using confirmatory factor analysis. Pearson's correlation was used to examine relationships among latent factor scores, and multivariate linear regression models were used to determine if factor scores significantly differed across socio-demographic characteristics. The DWE measures consisted of latent factors of the physical domain (frequency of common domestic tasks, water sourcing and carriage, experience of water scarcity), the psychosocial domain (stress appraisal and demand-control), and the social domain (social support). Significant correlations were observed among the latent factors within and across domains. Results revealed the importance of measuring rural Nigerian women's DWE using multiple and contextual approaches rather than relying solely on one exposure measure. Multiple inter-related factors contributed to women's DWE. Water insecurity exacerbated the physical and emotional demands of domestic labor DWE varied across age categories and pregnancy status among rural Nigerian women.

Diverse Health, Gender and Economic Impacts from Domestic Transport of Water and Solid Fuel: A Systematic Review

(1) Background: Water and solid fuel collection and transport are domestic duties for millions of households across the globe. People in areas with limited or no access to safely managed sources of water and household energy must fetch these resources on a frequent basis. The health, gender, and economic impacts associated with water and solid fuel collection labor have not been systematically reviewed. (2) Methods: Studies were identified through database searches and included using a list of inclusion and exclusion criteria. Studies were summarized and grouped into one of eight thematic categories. (4) Conclusions: The findings suggest that a diverse and heavy health burden is associated with water and solid fuel collection and transport. The literature also suggests that the provision of safely managed and accessible water and improved fuel options can mitigate these negative outcomes. Filling research gaps and utilizing results to guide policy and funding would likely be an effective way to ensure low- and middle-income countries are not left behind as the world strives to meet the sustainable development goals.

Reduced water collection time improves learning achievement among primary school children in India

In low-and-middle-income countries, the provisioning of safe drinking water is a challenge that will likely worsen with climate change. Securing water will require more work and time, burdening women and children the most. Currently, the consequences of this time burden to children's development remain understudied. To address this gap, we examine the tradeoff between children's household water collection responsibilities and learning achievement. Using nationally representative data from India, we measure the effect of daily fetching time on primary school children's learning achievement in a two-stage regression model, with rainfall as the instrument. Our analyses indicate that higher fetching times predict lower mathematics (-1.23 standard deviations, 95CI[-2.32, -0.14]), reading (-1.13 standard deviations, 95CI[-2.07, -0.19]), and writing (-1.21 standard deviations, 95CI[-1.89, -0.51]) test scores. These effects are heterogeneous across sex and infrastructure type. For example, we find girls' mathematical and reading skills profit more from reductions in fetching time than boys' (score less affected for boys by β amount: mathematics: β=0.26 points, 95CI[0.095, 0.42]; reading: β=0.27 points, 95CI[0.054, 0.49]). Children using hand pumps, open wells, or tube wells are hurt more academically in mathematics and writing by increases in fetching time than children with mostly off-premises piped access (e.g., writing scores more affected by β amount: hand pump: β=-0.18, 95CI[-0.29, -0.081]; open well: β=-0.18, 95CI[-0.33, -0.040]; tube well: β=-0.14, 95CI[-0.29, -0.00072]). Given these results, we recommend off-premises piped infrastructure in the absence of piped-to-premises water in water-insecure contexts and offer guidance for targeting infrastructure investments in India.

Effects of human variation on foot and ankle pain in rural Madagascar

OBJECTIVES

Foot and ankle dysfunction in barefoot/minimally shod populations remains understudied. Although factors affecting musculoskeletal pain in Western populations are well-studied, little is known about how types of work, gender, and body shape influence bone and joint health in non-Western and minimally shod communities. This study examines the effect of human variation on locomotor disability in an agrarian community in Madagascar.

MATERIALS AND METHODS

Foot measurements were collected along with height, weight, age, and self-report data on daily activity and foot and ankle pain from 41 male and 48 female adults. A short form revised foot function index (FFI-R), that measures functional disability related to foot pain, was calculated. Raw and normalized foot measurements were compared by gender and used in a multiple linear regression model to determine predictors of FFI-R.

RESULTS

Compared to men, women reported higher FFI-R scores (p = 0.014), spent more time on their feet (p = 0.019), and had higher BMIs (p = 0.0001). For their weight, women had significantly smaller and narrower feet than men. Bimalleolar breadth (p = 0.0005) and foot length (p = 0.0223) standardized by height, time spent on feet (p = 0.0102), ankle circumference standardized by weight (p = 0.0316), and age (p = 0.0090) were significant predictors of FFI-R score.

DISCUSSION

Our findings suggest that human variation in anatomical and behavioral patterns serve as significant explanations for increased foot and ankle pain in women in this non-Western rural population. Foot and ankle pain were prevalent at similar levels to those in industrialized populations, indicating that research should continue to examine its effect on similar barefoot/minimally shod communities.

Towards an integrated theoretical framework for understanding water insecurity and gender-based violence in Low-and middle-income countries (LMICs)

Disparities in access to basic needs and resources such as water is largely borne out of power imbalance across scale. In examining these power dynamics in the context of health inequalities, scholars have deployed Feminist political ecology analytical framework to situate gender and other forms of vulnerability as emerging from unequal power relations, and political ecology of health to emphasise the health implications of inherent relational power in the distribution of resources. Although appealing, the two theoretical frameworks over time have proven to be limiting in the study of intersectional vulnerabilities such as gender-based violence and water insecurity which reflect multiple dimensions of unequal power structures. This study expands the theoretical space for the study of inequalities in health geography by demonstrating the utility of incorporating feminist political ecology with political ecology of health to form an integrated theoretical framework - Feminist Political Ecology of Health (FPEH). This proposed theoretical framework gives guidance for engaging with a suite of questions and methods related to multifaceted problems such as water insecurity and gender based-violence. The paper highlights these theoretical issues and then discusses how FPEH can enrich research on water security and gender-based violence in Low-and middle-income countries (LMICs).

Successes, challenges, and support for men versus women implementers in water, sanitation, and hygiene programs: A qualitative study in rural Nepal

INTRODUCTION

Women's active participation is important for inclusive water, sanitation, and hygiene (WaSH) programs, yet gender roles that limit women's access to formal education and employment may reduce their skills, experience, and capacity for implementation. This paper explores differences between men and women implementers of rural WaSH programs in implementation approaches, challenges, and sources of support for implementation, and success in achieving program quality outcomes.

METHODS

We interviewed 18 men and 13 women in community-based implementation roles in four districts of Nepal. We identified challenges and sources of support for implementation in four domains-informational, tangible, emotional, or companionship-following social support theory. We assessed successes at achieving intermediate implementation outcomes (e.g., adoption, appropriateness, sustainability) and long-term intervention outcomes (e.g., community cleanliness, health improvements).

RESULTS

Women used relational approaches and leveraged social ties to encourage behavior change, while men used formative research to identify behavior drivers and sanctions to drive behavior change. Women experienced stigma for working outside the home, which was perceived as a traditionally male role. Companionship and emotional support from other women and male community leaders helped mitigate stigma and lack of informational support. Women were also more likely to receive no or low financial compensation for work and had fewer opportunities for feedback and training compared to men. Despite lack of support, women were motivated to work by a desire to build their social status, gain new knowledge, and break conventional gender roles.

CONCLUSIONS

Both men and women perceived that women were more effective than men at mobilizing widespread, sustained WaSH improvements, which was attributed to their successes using relational approaches and leveraging social ties to deliver acceptable and appropriate messages. Their skills for motivating collective action indicate that they can be highly effective WaSH implementers despite lack of technical experience and training, and that women's active participation is important for achieving transformative community change.

Interpersonal Conflict over Water Is Associated with Household Demographics, Domains of Water Insecurity, and Regional Conflict: Evidence from Nine Sites across Eight Sub-Saharan African Countries

Water insecurity may precipitate interpersonal conflict, although no studies to date have rigorously examined these relationships. We examined relationships between household demographics, water insecurity, regional conflict, and interpersonal conflict over water. Using survey data from eight sub-Saharan African countries, we found that interpersonal conflict within and outside the home is associated with multiple domains of water insecurity, particularly accessibility. Furthermore, we found that higher levels of remote violence and protests are associated with greater within household conflict, whereas riots and violent armed conflict are associated with greater conflict between neighbors. Our findings expand upon the current literature by examining factors affecting interpersonal conflict over water, which may become increasingly important as precipitation patterns and land temperatures change in this region.

A meta-analysis of the association between physical demands of domestic labor and back pain among women

Background

Back pain (BP) is among the most common musculoskeletal problems globally and is a leading contributor to disability among adults. Millions of women especially those in low-income settings, engage in strenuous domestic activities that may increase their risk of BP. The purpose of this meta-analysis was to estimate the association between physically demanding domestic labor (PDDL) which is characterized as intensity, frequency, duration of work and biomechanical risk factors of work and BP among women.

Methods

Five databases were searched for records published from January 1991 to March 2020; and results from 11studies were included in the meta-analysis. A random effects model and the generic inverse-variance method was used to estimate the pooled odds ratio (OR), 95% confidence interval (CI), and the degree of heterogeneity among studies (I²). Stratified and sensitivity analyses were conducted to identify the influence of outliers and identify the sources of heterogeneity.

Results

Exposure to high PDDL was significantly associated with BP (OR = 1.63; 95% CI 1.30, 2.04; I² = 70%). The odds of back pain were highest among the following groups: women performing domestic labor in non-neutral postures (OR = 2.30; 95% CI = 1.75–3.04; I² = 0%; N = 4 studies) and among women from low- and middle-income countries (OR = 1.98; 95% CI = 1.58–2.49; I² = 29%; N = 5 studies). We found no evidence of publication bias (Egger’s test p-value = 0.15).

Conclusions

PDDL may significantly increase a woman’s risk of experiencing BP, but larger prospective studies are needed to further investigate the association. Presenting data on how domestic work affects the musculoskeletal health of women will be important in designing future interventions (behavioral, infrastructural, and ergonomic) that can reduce the burdens from domestic labor.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-021-01294-5.

The interrelationship between water access, exclusive breastfeeding and diarrhea in children: a cross-sectional assessment across 19 African countries

Background

Access to an improved water supply and practicing exclusive breastfeeding are essential for improving maternal and child health outcomes. However, few studies have been equipped to assess the interdependencies between access to improved water, practicing exclusive breastfeeding, and child health. The primary aim of our study was to assess whether access to an improved water supply and water-fetching were associated with mothers’ practice of exclusive breastfeeding.

Methods

We analyzed data on 247 090 mothers with children 5 months old or less using Multiple Indicator Cluster Surveys from 19 African countries. Multivariable logistic regression was used to estimate the relationship between our exposures and exclusive breastfeeding practice, while meta-analytic methods were used to pool adjusted estimates across 19 countries.

Results

The prevalence of exclusive breastfeeding ranged from 22% in Nigeria to 70% in Malawi. Pooled results showed water-fetching was not associated with exclusive breastfeeding (adjusted prevalence odds ratios (aPOR) = 1.04, 95% confidence interval (CI) = 0.89, 1.21). Access to an improved water source was also not associated with exclusive breastfeeding (aPOR = 1.06, 95% CI = 0.94, 1.21). Across all countries many women were spending a significant amount of time water-fetching each day (mean time varied from 20 minutes in Ghana to 115 minutes in Mauritania). Exclusively breastfed children had 33% lower odds of diarrhea than those who were not exclusively breastfed (aPOR = 0.67, 95% CI = 0.56, 0.78).

Conclusion

Our study is the first to assess the relationship between access to improved water supply, water-fetching and exclusive breastfeeding. We found that access to water supply and time spent by mothers fetching water were not associated with exclusive breastfeeding practice, even though mothers spent significant time fetching water.

The interrelationship between water access, exclusive breastfeeding and diarrhea in children: a cross-sectional assessment across 19 African countries

BACKGROUND

Access to an improved water supply and practicing exclusive breastfeeding are essential for improving maternal and child health outcomes. However, few studies have been equipped to assess the interdependencies between access to improved water, practicing exclusive breastfeeding, and child health. The primary aim of our study was to assess whether access to an improved water supply and water-fetching were associated with mothers' practice of exclusive breastfeeding.

METHODS

We analyzed data on 247 090 mothers with children 5 months old or less using Multiple Indicator Cluster Surveys from 19 African countries. Multivariable logistic regression was used to estimate the relationship between our exposures and exclusive breastfeeding practice, while meta-analytic methods were used to pool adjusted estimates across 19 countries.

RESULTS

The prevalence of exclusive breastfeeding ranged from 22% in Nigeria to 70% in Malawi. Pooled results showed water-fetching was not associated with exclusive breastfeeding (adjusted prevalence odds ratios (aPOR) = 1.04, 95% confidence interval (CI) = 0.89, 1.21). Access to an improved water source was also not associated with exclusive breastfeeding (aPOR = 1.06, 95% CI = 0.94, 1.21). Across all countries many women were spending a significant amount of time water-fetching each day (mean time varied from 20 minutes in Ghana to 115 minutes in Mauritania). Exclusively breastfed children had 33% lower odds of diarrhea than those who were not exclusively breastfed (aPOR = 0.67, 95% CI = 0.56, 0.78).

CONCLUSION

Our study is the first to assess the relationship between access to improved water supply, water-fetching and exclusive breastfeeding. We found that access to water supply and time spent by mothers fetching water were not associated with exclusive breastfeeding practice, even though mothers spent significant time fetching water.

PROTOCOL: Water, sanitation and hygiene for reducing childhood mortality in low- and middle-income countries

Respiratory tract infections and diarrhoea are the two biggest killers of children in low income contexts. They are closely related to access to, and use of improved water, sanitation and hygiene (WASH). However, there is no high quality systematic review that quantifies the effect of WASH improvements on childhood mortality. Existing systematic reviews of WASH improvements measure effects on morbidity, under the (often implicit) assumption that morbidity is closely correlated with mortality. This is at least partly because the impact evaluations on which they are based are only designed to detect changes in morbidity with statistical precision, whereas mortality is a relatively rare outcome. The proposed review will address this evidence synthesis gap, using the greater statistical power of meta-analysis to pool findings across studies.

Water quality, sanitation, and hygiene among the tribal community residing in Jawadhi hills, Tamilnadu: An observational study from Southern India

Objectives:

To assess the water, sanitation, and hygiene (WASH) practice among the tribal population of Tamil Nadu, India and to determine the physiochemical and bacteriological quality of drinking water at the principal source and at the households along with the household-level determinants of WASH practices.

Methods:

A door-to-door survey was conducted in 150 households, distributed across six villages of Jawadhi hills, a tribal area in the state of Tamil Nadu, India. Water samples were collected from the principal sources and a subset of households for assessing water quality. A composite scoring was formulated to determine the overall WASH practices.

Results:

Overall, a poor WASH score (≤4) was found in 103 (68.7%; 95% CI: 60.7, 75.6) households. The majority (96.7%) of the household water samples showed the presence of fecal coliforms. Poor WASH score was uniformly distributed across the villages. Low per capita income (≤1000 INR) was strongly associated with the poor WASH score (Adjusted OR 2.4; 95% CI: 1.04, 5.7). The per capita income had a strong negative association with the high fecal coliform count (Adjusted OR 5.07; 95% CI: 1.08, 23.74).

Conclusions:

We conclude that WASH-related practices among the tribal population of Tamil Nadu is not acceptable. The lack of administrative function and poor economic conditions are the likely causes attributed to the poor WASH conditions and drinking water quality. Urgent action from the stakeholders is the need of the hour to improve the water quality and living standards of such marginalized populations.

Household practices in accessing drinking water and post collection contamination: A seasonal cohort study in Malawi

Lack of access to safe drinking water on premises remains widespread in low- and middle-income countries. Interventions to improve access to safe water at the point of collection are essential, but water safety at the point of consumption is also an important consideration. This research aimed to 1) improve understanding of household practices in collecting water with respect to seasonality, and 2) to further assess risk associated with post-collection contamination from the point of collection to the point of consumption. A seasonal cohort study, including 115 households, was conducted in Malawi. Along with household surveys and observations, samples of water were tested for microbial water quality at four different stages of water collection: water source, collection container, storage container, cup of drinking water. Using E. coli as an indicator of contamination (cfu/100 ml), the risk of post-collection contamination was assessed. The results indicate that most water sources were free from contamination; contamination was proportionally lower in the dry season when more sources were found to be classified as having a very low risk of contamination. However, the level of risk of contamination was more likely to increase following collection in water sources that were initially free from contamination. Results show that the degradation in water quality from the point of collection to the point of consumption was more important in the rainy season, which is likely to be driven by the effect of seasonality on the household environment. Filling the collection container at the point of collection and storage at the point of consumption were found to be critical stages for an increased risk of E. coli contamination. Understanding household practices in accessing and handling water during both rainy and dry season is necessary to target appropriate interventions to reduce post-collection contamination.

Evaluating self-reported measures and alternatives to monitor access to drinking water: A case study in Malawi

Monitoring access to drinking water is complex, especially in settings where on premises water supply is not available. Although self-reported data are generally used to estimate coverage of access to drinking water, the relationship between self-reported time travelled and true time travelled is not well known in the context of water fetching. Further, water fetching is likely to impact the quantity and quality of water a household uses, but data and measures supporting this relationship are not well documented. The objective of this study was to appraise the validity and reliability of self-reported measurements used to estimate access coverage. A case study was conducted in Malawi to enhance understanding of the self-reported measures and alternatives available to assess and monitor access to drinking water in view of generating global estimates. Self-reported data were compared with objective observations and direct measurements of water quantity, quality and accessibility. Findings from this study highlight the variations between different measures such as self-reported and recorded collection time and raise awareness with regard to the use of self-reported data in the context of fetching water. Alternatives to self-reported indicators such as GPS-based or direct observations could be considered in surveys in view of improving data accuracy and global estimates.

Trends in access to water and sanitation in Malawi: progress and inequalities (1992-2017)

Billions of people globally gained access to improved drinking water sources and sanitation in the last decades, following effort towards achieving the Millennium Development Goals. Global progress remains a general indicator as it is unclear if access is equitable across groups of the population. Agenda 2030 calling for `leaving no one behind', there is a need to focus on the variations of access in different groups of the population, especially in the context of low- and middle-income countries including Malawi. We analyzed data from Demographic Health Survey (DHS) and Multiple Indicator Cluster Survey (MICS) to describe emerging trends on progress and inequalities in water supply and sanitation services over a 25-year period (1992-2017), as well as to identify the most vulnerable populations in Malawi. Data were disaggregated with geographic and socio-economic characteristics including regions, urban and rural areas, wealth and education level. Analysis of available data revealed progress in access to water and sanitation among all groups of the population. The largest progress was generally observed in the groups that were further behind at the baseline year, which likely reflects good targeting in interventions/improvements to reduce the gap in the population. Overall, results demonstrated that some segments of the population - foremost poorest Southern rural populations - still have limited access to water and are forced to practise open defecation. Finally, we suggest including standardized indicators that address safely managed drinking water and sanitation services in future surveys and studies to increase the accuracy of national estimates.

Water and mental health

There is a well‐established connection among water quality, sanitation, and physical health. The potentially important relationship between water and mental health is considerably less studied. Reviewing evidence from ethnography, geography, folklore, indigenous studies, rural medicine, drought research, and large‐n statistical studies, we argue there is now good theoretical rationale and growing evidence of water insecurity as a possible driver of mental ill‐health. Furthermore, some nascent evidence suggests that emotionally meaningful interactions with water might improve mental health outcomes. Leveraging these literatures, we address the many ways in which mental health outcomes are conceptualized and operationalized in water research, including as emotional distress, perceived stress, depressive symptoms, anxiety symptoms, somatic symptoms, and quality of life. We outline arguments supporting seven possible (and likely interlocking) mechanisms that could explain such a relationship: (a) material deprivation and related uncertainty, (b) shame of social failure, (c) worry about health threats, (d) loss of connections to people and places, (e) frustration around opportunity losses and restricted autonomy, (f) interpersonal conflict and intimate partner violence, and (g) institutional injustice or unfairness. However, we explain that as most existing studies are ethnographic, qualitative, or cross‐sectional, a causal relationship between water and mental ill‐health is yet to be confirmed empirically. More research on this topic is needed, particularly given that poorly understood connections may create barriers to achieving Sustainable Development Goals 3 (health) and 6 (water). We further suggest that tracking mental health indicators may provide unique and as‐yet underappreciated insights into the efficacy of water projects and other development interventions.

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Water risk perceptions across the life-course of women in Kenya

Inadequate access to water, sanitation and hygiene (WaSH) exposes many vulnerable populations, especially women and girls, to preventable diseases around the world. This paper reports findings from a photovoice project that explored water-related risk perceptions and health outcomes among women in Nyanchwa, Kenya. Thirteen women in four age categories were recruited for this study in July 2016 using the 'snowball' technique. From the results, inadequate access to WaSH was associated with increased water collection burden on women and children; environmental pollution; poor educational outcomes; loss of time due to water collection and poor sanitation infrastructure. Some barriers to change identified include financial barriers and inadequate government support. The identified risks and barriers are important considerations for the design, evaluation and mainstreaming of WaSH programs in resource constrained settings.

Alternative Water Transport and Storage Containers: Assessing Sustained Use of the PackH2O in Rural Haiti

The PackH₂O water backpack carrier was developed to provide safe storage and relieve stress of head-loading during water transport with traditional containers such as buckets and jerry cans. We conducted an evaluation to assess both self-reported and observed use over a 6-month period between November 2014 and May 2015. A total of 866 packs were distributed to 618 households in six communities in rural Haiti, and 431 and 441 households were surveyed at midline and end line, respectively. We performed linear regression to assess change of self-reported use over time. Although 79.3% of respondents reported continued use of the 20-L pack after 6 months, other measures of self-reported use were low, with only 16.8% reporting to have used the pack the last time they collected water and 10.3% preferring the pack over other water collection containers. In addition, only 10.2% of all people collecting water at community sources were observed using packs and 12.0% of all households surveyed had water in the pack at the time of visit. Pack use varied by community and demographics. Although women were targeted during distribution, men preferred the pack and were more commonly observed using it at the community water sources. In conclusion, the use of the PackH₂O was not widely adopted in rural Haiti; however, further research is needed to assess the pack acceptance in areas where back-loading is more common and in emergency settings.

Concept mapping: Engaging stakeholders to identify factors that contribute to empowerment in the water and sanitation sector in West Africa

Research has shown that inadequate access to water, sanitation, and hygiene (WASH) affects women and girls in several ways, including lowering their participation in the labour market and community activities and contributing to psychosocial stress and poor educational outcomes. There is growing awareness that addressing the gender inequalities related to WASH that many women and girls face on a daily basis must go beyond focusing on delivery of infrastructure and facilities alone and include attention to issues of empowerment. Yet there is limited exploration of how the concept of empowerment is defined and applied in the WASH sector and thus limited information on how it could be measured. This study used concept mapping to uncover the meaning and key dimensions of empowerment in WASH among 34 and 24 stakeholders in Asutifi North District, Ghana, and Banfora Commune, Burkina Faso, respectively. The study was part of initial steps toward choosing indicators for developing an Empowerment in WASH Index. In Ghana and Burkina Faso, 42 and 29 items were generated, respectively. These items were thought to empower men and women in WASH at the household and community levels. In both case studies, 7 clusters were generated and named by participants, and themes related to sharing of information, sociocultural norms, participation, and accessibility of WASH services were associated with empowerment. Some themes were unique to each case study site. Participants also showed a multidimensional and multilevel understanding of empowerment. Concept mapping created an effective balance between individual and group contributions and facilitated accessible, rapid, and contextually relevant data collection. The findings can be used to generate domains of empowerment in future quantitative research as well as inform the design of the Empowerment in WASH Index.

Decomposing gender inequalities in self-assessed health status in Liberia

Background: Understanding the magnitude of inequalities and drivers for reducing gender-related health inequalities is crucial in developing countries. This is particularly the case for Liberia with its very high level of gender-related inequalities in health and health outcomes.

Objective: This paper assesses the magnitude of gender health inequalities and the relative contribution of different factors to health inequality in Liberia.

Methods: Data came from the Liberian Household Income Expenditure Survey 2014. A two stage sampling methodology was used and 4,104 households were randomly selected and interviewed. The main variable of interest is dichotomised, good versus poor self-assessed health. Gender-related health inequality is assessed using the Oaxaca–Blinder decomposition for non-linear models. The decomposition reveals the magnitude of inequality and contributions of different factors.

Results: We found large gender disparities (0.054, p < 0.01) characterised by women disadvantages in health status. In addition, the gender health disparities are mostly pronounced in rural areas. About 54% of the gender inequalities in health status were explained by the differences in endowments. Equalizing access to information, wealth and utilization of mosquito nets would reduce the gender gaps by 44, 5 and 4%, respectively.

Conclusions: Addressing gender health inequalities inter alia requires access to health information (i.e. electronic and print media), gender responsive interventions that improve wealth in key sectors (i.e. education, employment, social protection, housing, and other appropriate infrastructure). In addition, the government, private sector and civil society should ensure that the health sector provides access to quality mosquito nets and improved health services including preventive care in order to reduce disease burden.

The association of water carriage, water supply and sanitation usage with maternal and child health. A combined analysis of 49 Multiple Indicator Cluster Surveys from 41 countries

BACKGROUND

Millions of people carry water home from off-plot sources each day and lack improved sanitation. Research on the health outcomes associated with water fetching is limited, and with usage of improved sanitation is inconclusive.

OBJECTIVES

To analyse the association of water fetching, unimproved water supplies, and usage of improved sanitation facilities with indicators of women's and children's health.

METHODS

49 Multiple Indicator Cluster Surveys from 41 countries were merged, creating a data set of 2,740,855 people from 539,915 households. Multilevel, multivariable analyses were conducted, using logistic regression for binary outcomes, negative binomial regression for count data and ordinary linear regression for linear data. We adjusted for confounding factors and accounted for clustering at survey, cluster and household level.

RESULTS

Compared to households in which no-one collects water, water fetching by any household member is associated with reduced odds of a woman giving birth in a health care facility (OR 0.88 to 0.90). Adults collecting water is associated with increased relative risk of childhood death (RR 1.04 to 1.05), children collecting water is associated with increased odds of diarrheal disease (OR 1.10 to 1.13) and women or girls collecting water is associated with reduced uptake of antenatal care (β-0.04 to -0.06) and increased odds of leaving a child under five alone for one or more hours, one or more days per week (OR 1.07 to 1.16). Unimproved water supply is associated with childhood diarhhoea (OR 1.05), but not child deaths, or growth scores. When the percentage of people using improved sanitation is more than 80% an association with reduced childhood death and stunting was observed, and when more than 60%, usage of improved sanitation was associated with reduction of diarhhoea and acute undernutrition.

CONCLUSION

Fetching water is associated with poorer maternal and child health outcomes, depending on who collects water. The percentage of people using improved sanitation seems to be more important than type of toilet facility, and must be high to observe an association with reduced child deaths and diarhhoea. Water access on premises, and near universal usage of improved sanitation, is associated with improvements to maternal and child health.